Program/Service Information for BHT Hub

Program/Service Information for BHT Hub
Thank you for your interest in displaying or updating your information. This form will be used to create informational pages on our Behavioral Health Taskforce Resource Hub. If you only wish to add one program or service, please fill out section 1. For multiple programs/services, please fill out sections 1 and 2.

Section 1: One Program/Service

1. Contact Information

Organization Name

Street Address

Apt/Suite/Office

City

State

Zip

Email Address

Phone Number

Website

2. If you have a logo for your organization, please upload it here:

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3. Programs and Services Offered

4. Who Your Program Serves (Adult, Youth, etc.)

5. Hours of Operation/ Availability

6. Accepted Payments (MA, Private Insurance, Non-insured payment methods)

7. Does your program provide services in Languages other than English?

8. If Yes, Please list available languages:

8. What is your organization's preferred referral process?

9. If you have a referral form you use, please upload it here:

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10. Are you accepting new clients at this time?

11. If yes, how many?

11. If no, what is your current wait time?

11. Telehealth Services Available

Section 2: Multiple Programs/Services
If your program has multiple programs and services with specific information and providers or contact persons, please fill out the information below for each program/service that you would like displayed. If this does not apply, please submit the form. Thank you!

12. Program/Service Name and Description

13. Who Your Program Serves (Adult, Youth, etc.)

14. Contact Information

First Name

Last Name

Email Address

15. Program/Service Name and Description

16. Who Your Program Serves (Adult, Youth, etc.)

17. Contact Information

First Name

Last Name

Email Address

18. Program/Service Name and Description

19. Who Your Program Serves (Adult, Youth, etc.)

20. Contact Information

First Name

Last Name

Email Address